The organizational and administrative aspects of practice facilitation programs have been summarized recently in an AHRQ publication, “Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide”, which addresses some of the financial issues faced during practice transformation. Many financial models are possible. However, in the context of a nationwide extension program, two types of funding are likely to be important, sustainable funding and project-specific funding.

Sustainable funding could come from federal, state and/or local governments, health insurance companies, and local businesses. All of these entities could expect to gain financially from their investment. Evidence supporting a return on investment from facilitated improvements in delivery of preventive services was published by Hogg in 2005. Project-specific funding could come from a large number of sources including federal (e.g. Office of the National Coordinator for HIT, Centers for Disease Control and Prevention, Health Resources Services Administration, National Institutes of Health, Deparmtent of Defense, and AHRQ), state (e.g. tobacco settlement funds) and local governments, private foundations and other non-profits (e.g. The Patient-Centered Outcomes Research Institute), and local industries.

In New Mexico, funding for health extension has come from a variety of sources, including university special appropriations, project-specific grants from state and national entities, and partnerships with community organizations. More information about how New Mexico has financed health extension can be found at right.

Partnerships in Challenging Times

The current economic crisis has led to decreased funding for many programs and initiatives– from core funding rescissions from State funds, to fewer (and more competitive) grant opportunities. The silver lining to this dark cloud has been the increased collaboration between previously-siloed departments, increased partnership between the university and the community, and more effective use of funds, including cost-sharing for staff and programs.

“Shared Resources” have become increasingly necessary, not only for small, independent practices, but for community organizations as well, leading to alignment of priorities and programming across the state. The University of New Mexico Health Sciences Center adopted their Vision 2020, which is “Partnering with communities, we will improve health and health equity more than any other state by 2020.” In order to reach this vision, the HSC has recognized that we must move beyond competition and better align our priorities, resources, and strategies in partnership with other people, organizations, and institutions in our state.

Vision 2020

The UNM HSC Vision 2020 – “University of New Mexico Health Sciences Center will work with community partners to help New Mexico make more progress in health and health equity than any other state by 2020” came from the leadership of the HSC as a way to support the improved health of New Mexico communities.

Vision 2020 creates the first academic health center strategic plan that focuses on improving a state’s population’s health and health equity as a measure of the institution’s success. To fulfill this Vision, all colleges, schools, departments and programs at UNM HSC have incorporated into their annual performance plans how their education, service and research enterprises will measurably improve the health of New Mexico.

The key behind Vision 2020 is learning as an academic health center to respond to the community priorities as opposed to our own. Also, through alignment of activities and strategies we can use resources more effectively and have a larger impact on community health. A major tool in accomplishing this vision is through the use of health extension. When the institution has a full-time staff person form the local communities who lives in the communities it serves it can respond more quickly and effectively to the needs.

This is part of a national movement for Academic Health Centers to measure their success by the health of the communities they serve. An institutional commitment through the adoption of the vision has been an essential piece of this goal, as well as the integration of this vision into the work of all the colleges, departments, and offices.

We will do this by focusing on evidence-based interventions and evidence-informed policy, by disseminating and building on successful programs and pilots, and by linking and aligning existing resources to address community priorities for improving health and health equity.

The terms “health equity” and “health disparities” are used frequently in our vision and in the reports; for clarification, “health disparity” is a difference between health outcomes between a persistently socially disadvantaged group and one that has a higher relative position in the social hierarchy. “Health equity” is the pursuit of the elimination of these disparities.

Health Extension Hubs

The University of New Mexico Health Sciences Center (UNM HSC)/Community Academic Extension Hubs refers to community-based organizations, institutions, or programs in a particular region that make an arrangement with UNM HSC to serve as a local extension of the HSC in areas of interest to them: education, service, research and/or policy.

The concept has grown out of lessons learned from different campus-community models—the agricultural Cooperative Extension Service, Health Extension Rural Offices (HEROs), rurally-based residencies, and memorandums of agreement between community hospitals or community health centers and UNM HSC. These models reflect the value of decentralizing the resources of UNM HSC to local communities to better response to community health priorities.

Creation of local Academic Extension Hubs facilitates community capacity-development in health through community access to numerous HSC resources in areas as diverse as pipeline development, workforce development, telehealth, clinical service improvement, community-based education, program evaluation and research. Having full-time, community-based, UNM HSC-affiliated personnel helps UNM HSC improve its knowledge of and response to community needs.

Finally, the development of Academic Extension Hubs is an important vehicle for helping UNM HSC fulfill its Vision 2020: UNM HSC will work with community partners to help New Mexico make more progress in health and health equity than any other state by 2020.

Examples of Successful Partnerships

Medicaid Managed Care: Health extension is an important resource and potential source of sustained funding for Health Extension. As described in Module VI C.3, Medicaid Managed Care has been shown to be a significant, long term funder of health extension through health extension’s role as trainers and supervisors of community health workers. In addition, because Medicaid Managed Care is a capitated system, interventions that remove barriers to accessing primary care and basic, supportive services are items in which Medicaid Managed Care companies in New Mexico have invested. All are tied to roles Health Extension plays. Such items include improved health literacy and ability to navigate the complex health system, access to transportation to clinics and social services, assistance in enrolling in entitlement programs and access to adequate nutrition, education and housing.

Community Hospitals: Community hospitals, especially non-profits are now obligated to demonstrate community benefit by conducting periodic community health assessments and by implementing programs based on their findings. Some hospitals have found that Health Extension can play a role in each task and have funded their own agent. As primary care providers are increasingly employed by larger systems, hospitals have emerged as major employers of primary care. Health Extension can serve a supportive role in that transition. In addition, hospital relationships with different ethnic communities is enhanced when hospital liaisons with those communities is strengthened. Health Extension can offer value in that regard.

Health Information Technology Regional Extension Centers: Through Recovery Act funding, many states received funding from the U.S. Dept of Health and Human Services to establish Regional Extension Center to help physician practices and hospitals adopt electronic medical records and implement their meaningful use. Practices that made this conversion could receive ~$40,000-$60,000/provider demonstrating this achievement. Such an achievement was a major component of becoming an NCQA-certified Patient-Centered Medical Home. In New Mexico, LCF Research, a non-profit received the federal funding to establish the HITREC and sent EMR coaches to all the state’s primary care practices. LCF Research then approached the HEROs program to help practices address the social transformation of the practice—improving clinic team work, each employee achieving their highest level of functioning, assuming new roles.

Clinical and Translational Science Centers: Academic health centers play a unique role in the healthcare system in education and research. By and large, faculty invest heavily in their research roles. With the impetus of CTSC funding and expectations, the role of community engagement in research is growing, bolstered by the twin, parallel growth of practice-based research networks, community-based participatory research. However, most traditional community-based research is based at universities with community links resting upon outreach activities rather than universities working through agents that live and work in the communities serves, knowing a great deal about assets and challenges of their communities which would be valued by researchers.

AHECs: When the Affordable Care Act was written, and Section 5405 “Primary Care Extension Program,” was included, many in the AHEC community were concerned for they felt the description of “Health Extension” was similar to the work of Area Health Education Centers. They felt they should be the rightful recipients of federal funding for this new initiative? There was some justification for that concern. For while the focus of AHEC is education and the focus of Primary Care Extension is primarily service, AHECs vary greatly across the country, with some having a significant role in service. Over time, instead of competing, the Health Extension programs in states funded by the Agency for Healthcare Research and Quality’s IMPaCT grant have usually partnered with their state AHEC programs. In some cases, AHECs take the lead in their Health Extension program. In New Mexico, some AHEC leaders wear two hats in their regions, serving as AHEC coordinators as well as Health Extension agents, able to access a different set of resources from each role for their communities.

Shared HERO Costs

One way New Mexico has been able to expand the health extension model across the state is by partnering with community organizations to share the salary costs of health extension agents. For example, the county government of the most densely populated county of the state saw the value of HEROs and, even during a time of budget cuts, added a line item for an “urban HERO” position. A community hospital in Santa Fe, New Mexico (Christus St. Vincent’s), building on a strong partnership for many years with the Family and Community Medicine residency, also hired its first HERO. Below is more information about the role that St. Vincent’s developed for their local HERO agent:

1. Plans, develops, implements and coordinates the Health Extension Rural Office (HERO) programs for the north central counties and for the Native American population.
2. Performs community liaison and outreach activities, acting as the main point of contact between the Hospital, the communities and UNM Health Sciences Center
3. Consults with health systems and local primary care practices in progressing toward the model of patient-centered medical homes, providing technical assistance, guidance and expertise
4. Establishes and maintains relationships with government, tribal and organizational agencies and officials to facilitate and promote service development; represent program initiatives and organizes institutional resources to promote these efforts

The funding for health extension, and in particular as it relates to primary care transformation, can also be visualized similarly to the payment system for utilities (water, sewer, electic/gas, etc). The graphic below demonstrates how a primary care extension service, when visualized as a shared “utility”, could support a whole range of activities in the improvement of primary care.